Provider Demographics
NPI:1629447305
Name:MORALES, JANISE
Entity Type:Individual
Prefix:
First Name:JANISE
Middle Name:
Last Name:MORALES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 E 30TH ST
Mailing Address - Street 2:APARTMENT 68
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-8205
Mailing Address - Country:US
Mailing Address - Phone:305-903-8102
Mailing Address - Fax:
Practice Address - Street 1:1616 CAPE CORAL PKWY W
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33914-6979
Practice Address - Country:US
Practice Address - Phone:305-903-8102
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-23
Last Update Date:2022-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL058248122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist